A Discussion on Obesity (That Isn’t Flagrantly Annoying)

If you want to watch the world go crazy, just become a specialist in something. Specialists arguing amongst themselves can reach a frenzied pitch of nonsense faster than the U.S. congressional chamber at an open bar.

Two shots of Wild Turkey and dude thinks he’s Thor.

One of the only ways to combat this kind of implosion is to bring in outside voices: relevant but removed, useful but tangential. As a fitness specialist, that means occasionally asking people outside my field about how they view and work with bodies.

Heidi Guenin is a public policy analyst out of Portland, Oregon. She has a masters in urban and regional planning from Portland State University and will be completing another in public health from Oregon Health and Science University in 2014. As someone who thinks about issues of health and fitness at the population level, I was eager to get her perspective on that omnipresent boogeyman haunting every discussion of exercise on the internet and beyond: obesity.

I hope you’ll find her views as refreshing as I did.

For those unfamiliar with the role of a public health policy maker, in 20 words or less, what do you do?

As a public health policy researcher and advocate, I examine population-level health behaviors and outcomes to better understand which policies are needed to support health. That’s more than 20 words, but if it’s ok, I’m going to use up a few more while I’m at it.

We are particularly interested in health inequalities: where one or more groups suffer a disproportionate share of an illness or disease. Sometimes these inequalities are natural due to differences in age, gender, or other variables. Sometimes they are the result of unfairness in our social, economic, and physical environments. Public health policy folks like myself want to understand this second group of inequalities and eliminate them.

Public policy advocates: warriors of social justice, only with fewer swords and more epidemiological data.

How do you translate data about the behavior of whole populations into usable information for individuals?

My job is to translate health data into policy prescriptions for the people who make public health decisions: politicians, administrators, etc. Decision-makers want to hear about the bottom line: the costs of any policies or programs that promote health. There are plenty of places where we can find numbers—staggeringly high numbers—that are being pinned on obesity (and therefore on fat people themselves). So instead of making the case for quality of life, better health outcomes, or safer and more livable communities, we often find ourselves making the case for reduced health care spending through reduced obesity. This might win us a few votes, but it certainly doesn’t attract many folks to our cause or inspire community members to join in the discussion.

So what you’re saying is that the idea of reducing public spending by reducing obesity gets policy makers all fired up, but doesn’t do much to inspire the people living in those communities. Why is there such a disconnect?

I wish I knew. I could blame it on the current political climate where it’s more common to assign blame than develop effective solutions, and where the call for individual responsibility trumps the need for compassion. Public investments—mechanisms designed to improve the well-being of society as a whole—are increasingly treated like private investments with a predictable return of investment. Even the economist in me doesn’t understand. We know that inequality is bad for our economy, and this focus on the cost of obesity only serves to increase health inequalities for people who are stigmatized. And I don’t imagine anyone ever decided to take a walk or hop on a bike because they were made to feel bad about their share of national health care costs.

Obesity is a very common topic in public health policy, and I’d argue that it receives far too much emphasis. The growing focus on the “obesity epidemic” and on the rising cost of medical spending have created an environment where it is too convenient and common for public health folks, myself included, to rely on obesity as a scapegoat.

So, is obesity even considered a “health outcome”?

A health outcome is thought of in terms of morbidity (illness) and mortality (death). So the question you’re really asking me is: “Is obesity an illness?” I don’t have an answer for you. It’s a very controversial question.

Just this year, the American Medical Association voted to classify obesity as a disease, contrary to the recommendation of its own Council on Science and Public Health. The Council had noted that body mass index (BMI) is a flawed metric and that labeling obesity as a disease would not serve to improve health outcomes. But the AMA’s new designation of obesity as a disease creates a stronger case for insurers to cover anti-obesity drugs and surgeries such as stomach-stapling.

If obesity is a disease, then if you’re obese, losing weight should be a goal in and of itself. But here’s the thing: you can be fat and still be metabolically healthy. We tell people that if they lose weight, they will reduce their risk of many diseases—including cardiovascular disease, diabetes, some types of cancer, and coronary heart disease—but increasing physical activity levels also results in these risk reductions, even if the physical activity doesn’t result in weight loss.

So I assume, then, it wasn’t the “obesity epidemic” that got you into this gig, right?

Heidi, being awesome.

I got started working on transportation issues, which came about mostly because I love the fun and freedom that comes with being able to ride my bike and walk around my neighborhood. But when I talk about bicycling from a public-health perspective, it’s easier to emphasize the health and financial benefits of obesity reduction. Which is just plain silly; I don’t want someone to take up bicycling just because it will help them lose weight. That’s a recipe for disappointment and frustration and doesn’t support sustainable healthy choices.

Doesn’t it? That may come as a surprise to many. Can you explain?

The researcher who first got me interested in the role that shame plays in behavior change is Brene Brown at the University of Houston. She’s written a couple of popular books on the subject of shame and guilt, and I’d definitely recommend those to anyone interested in examining how shame negatively affects our mental and physical health.

But stigma is more widely studied than shame. A 2010 literature review on obesity stigmatization found that “…weight stigma is not a beneﬁcial public health tool for reducing obesity. Rather, stigmatization of obese individuals threatens health, generates health disparities, and interferes with effective obesity intervention efforts.”

Approaches that are more oriented toward weight acceptance and empowerment, however, show great promise in helping people increase their physical activity.

How would you like to see the conversation change?

I’m not prepared to argue that there are no negative health outcomes that stem from obesity, but we all need to question many of our underlying assumptions about weight and how we support people trying to improve their health.

In my perfect world, we would advocate for better bike infrastructure and safer neighborhood streets, not because people might lose weight, but because they’d have more fun, sleep better, be less at risk for depression, cancer, heart disease, and a host of other illnesses. And we’d stop, even inadvertently, sending fat people the message that there is something inherently wrong with them.

Are there any organizations out there getting it right?

I’m a fan of the Health at Every Size model; they have many resources on their site. Health interventions that use weight acceptance as a foundation have been very successful; they have better retention rates and don’t result in as much weight cycling.

What is weight cycling?

Weight cycling, or yo-yoing, may be responsible for some of the mortality risk that is often attributed to obesity itself. The mechanism by which this happens is still being studied.

Obesity research has for too long just assumed as a given that weight loss is a positive and important goal. This even though there is much we don’t fully understand about the impact of obesity on health outcomes, even though much of the research does not account for physical activity or for unhealthy weight yo-yoing, even though overweight has been shown to be protective of health, even though we understand that shame and stigma are not effective ways to help people change their behavior.

So does knowing all these things affect the way you live?

As an individual struggling with how to translate this information into my daily life, I’ve settled on a few first steps:

I try my hardest to not make assumptions about a person because of their weight. Old habits die hard, but the research and my own cadre of fat fit friends make it harder and harder for me to buy into the idea that thin = healthy.

I also don’t exercise to lose weight. Even though that little voice in my head still speaks up sometimes to remind me that I’m still the same weight I was yesterday or last month or last year, there’s another voice, too. It reminds me that I’m going to have better sex today and sleep better tonight, that next time I’ll be able to run a little farther or lift a little more weight, and that I’m giving my future body the gift of many more years of riding my bike down forest trails or dancing the night away.

It is really refreshing to read something like this. I have a degree in Human Nutrition, and during my nutrition communication paper, I noticed that a lot of what the government and other groups were doing to encourage things like weight-loss and adoptions of other healthy behaviours was exactly what the scientific literature said not to do. I’m glad that someone is shifting away from “exercise is good for weight-loss” to the many other benefits of exercise.

I didn’t grow up obese, or even overweight. I am very obese now, but… it’s very difficult for me (or for the family members who get it) to convince others that obesity is a symptom of my health problems, not the cause of them.

Great article! I really appreciated this. I’ve lost a lot of weight recently and as part of that journey been doing a lot of reading and thinking about how we look at weight. It’s been fascinating, and a life changer. I love what Heidi is saying and I love that she is working towards those goals in a public sector. Thanks again!

Really good article.Too much is put on the unreliable BMI chart(it classes rugby players and powerlifters as obese??!!)The fitness industry focusses on weight loss far too much.Rarely do they talk of strength,stamina etc it’s all about that magic number on the scales!!!

I am not an American but the principle stands everywhere I think – perhaps not the policies but the general idea and blame game is becoming more and more common. I found that really interesting and refreshing to be honest, particularly since I had a good rant on my blog yesterday about people pushing the dreaded scales on others and emphasising weight and not health and happiness. It is something that I fear a great number of people are far from understanding.

the shame game truly doesn’t work. it just adds layers and layers on top and if someone’s an emotional or stress eater, well….! i don’t feel bad about my size any more. i am what i am. if someone feels the need to point out the size of my butt or my gut, that says more about them, thinking that i’m somehow unaware of how much space i take up, than it does me.

but since i started writing professionally – something i’ve wanted to do all my life but never had the courage – i’ve started fitting back into my “slimmer” clothes. instead of multiple X’s, most of the stuff i wear only has one. one pair of pants is a size 16 – haven’t worn them in *aeons*.

i think it’s because– well, first of all, it’s because i’m sitting at the computer banging away on a keyboard for 10 – 14 hours a day instead of stuffing back stuff because i’m bored doing stuff– but i think it’s because i’ve spent all these years in a state of dread: i know i’m a good writer – “but what if i’m not? what if i write something and everybody hates it? what if it turns out i’m just … nothing?” and that kind of thinking messes up the mind in so many ways, particularly since i’m pretty sure i wasn’t even aware i was afraid of failing. i always had an excuse why writing wasn’t going to happen – “not yet”. “maybe later”. “some day”. excuses tend to breed more excuses.

and because i’ve bitten the biggest bullet i had, none of the rest really bother me any more, y’know?

Fascinating. Thanks for facilitating this interview, it was really interesting! I have been overweight my whole life. Even my toddler pictures show that I was a chubster. Sadly, I let stigma rule much of my life until a couple of years ago when, after a lot of soul-searching (and reading), my attitude shifted from treating myself horribly (the things I would say to myself when I had an extra piece of bread at dinner, or when I could only walk and not run on the treadmill were horrendous) to basically what Heidi references in the last paragraph here (“It reminds me that I’m going to have better sex today and sleep better tonight, that next time I’ll be able to run a little farther or lift a little more weight…”). I’m still 240lbs, and although that’s down from 300, the things that I’m most proud of are not necessarily the change in the numbers on the scale, but the change in my body’s ability to do things like run a 13-minute mile, and my mind’s ability to be thankful instead of ashamed.

Such good food for thought. Thanks again, this was a nice empowering reminder to focus on what’s important – health instead of numbers.